Inflammatory Reaction Secondary to Immune Checkpoint Inhibitor Therapy Mimicking a Post-Operative Brain Abscess

Ankur R. Patel, Scott Connors, Zabihullah Wardak, James B Brugarolas, Toral R Patel

Research output: Contribution to journalArticle

Abstract

Background: Immune checkpoint inhibitors have revolutionized the treatment of many cancers, including melanoma, non-small cell lung cancer, and renal cell carcinoma. These therapeutics increase the activity of T cells against neoplastic cells, although the immune response generated also has the potential to target normal cells, resulting in immune related adverse events (irAEs). Most irAEs occur outside of the nervous system, but cases of limbic encephalitis, hypophysitis, optic neuritis, and pseudoprogression have been reported. Case Description: Here, we present a case of an intracranial irAE after neoadjuvant stereotactic radiosurgery and craniotomy for resection of a left parietal lobe metastasis. The patient presented with headache, right-sided apraxia, and a pronator drift 2 weeks after surgery. Imaging findings were suggestive of an intracranial abscess. The lack of fever, normal white blood cell count, and benign clinical appearance in the setting of combination nivolumab and ipilimumab therapy argued in favor of an irAE, however. After initiation of dexamethasone, the neurologic deficits resolved and the magnetic resonance imaging of the brain normalized over 7 weeks. Conclusions: This is the first report of an acute surgical-site irAE after stereotactic radiosurgery and craniotomy in a patient receiving nivolumab and ipilimumab. These immune-mediated responses can be treated with corticosteroids and close observation.

Original languageEnglish (US)
Pages (from-to)354-358
Number of pages5
JournalWorld Neurosurgery
Volume129
DOIs
StatePublished - Sep 1 2019

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Brain Abscess
Radiosurgery
Craniotomy
Limbic Encephalitis
Apraxias
Optic Neuritis
Parietal Lobe
Neurologic Manifestations
Leukocyte Count
Renal Cell Carcinoma
Non-Small Cell Lung Carcinoma
Abscess
Dexamethasone
Nervous System
Headache
Melanoma
Adrenal Cortex Hormones
Fever
Therapeutics
Magnetic Resonance Imaging

Keywords

  • Brain abscess
  • Brain metastasis
  • ICI
  • Immune checkpoint inhibitor
  • Inflammation
  • Ipilimumab
  • Kidney cancer
  • Nivolumab
  • Opdivo
  • RCC
  • Renal cell carcinoma

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Inflammatory Reaction Secondary to Immune Checkpoint Inhibitor Therapy Mimicking a Post-Operative Brain Abscess. / Patel, Ankur R.; Connors, Scott; Wardak, Zabihullah; Brugarolas, James B; Patel, Toral R.

In: World Neurosurgery, Vol. 129, 01.09.2019, p. 354-358.

Research output: Contribution to journalArticle

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